Providing care for the patient is the responsibility of nurses. Nurses are the one who are close with patients. They are responsible and accountable to make sure that the treatments and needs of patient are fulfilled. Medication administration is a part of the nurses’ responsibility in order to make sure clients get the correct medication as supposed. Medication administration error is a universal health care concern.Thus the strategy in improving medication administration system is important to enhance safety.

The administration of medication by nurses is the final step in a process that involves multiple steps carried out by a number of health professionals (medical practitioners, pharmacists and registered nurses). The accuracy, efficiency and safety of administration of medications rest primarily with nurses. Medication administration is an activity that is prone to errors, in part because of the development of new medical devices and new drug products that available to fulfill the demand in health care setting. Thus to prevent medication administration error, six rights should be main concern for the nurses in giving medication.

There are many type of medical error that leads to injury and may jeopardize patient’s safety. According to Hughes and Ortiz (2005) the most common type of medical error that happen universally is medication error. Senior citizens are at the highest risk of being affected by this type of errors, since they are the largest consumers of medication (New Tech Media, 2006). However, this is especially true in regards to medication errors. A proper understanding of the contributing factors that increase medication errors is the first step toward preventing them. There are many factors, such as training deficiencies, undue time pressure, and nursing shortages that may have contribute to medication errors. The amount of nursing education and the years of nursing experience are two factors that may have relationship to medication errors. Due to the fact that nursing staff is a large cost to hospitals, these organizations are constantly trying to manage expenses. This is supported by Yang (2003) who states “nursing professionals typically represent the largest employee group in hospitals, and have become a primary target for redesign measures”. Consequently, medication errors are costly and seem to be proportional to the staffing of nurses. Since nurses make up such a large portion of the staff population, it is important to understand the incidents that influence behind these medication errors. These issues of medication errors were present even at the time when Benjamin Franklin founded America’s first hospital and he stated that patients ultimately suffer and die without good nursing care (Clarke, 2003).

1.2 PROBLEM STATEMENT

Health care professional’s work is hectic and stressful. All the heavy workload had causes the nurses to pay much less attention in giving proper medication administration to patients.I discovered during my clinical posting that sometimes the nurses tend to take for granted so as whether the patient did consume the medications given or not after leaving the medication on the patient’s bedside .

Occasionally proper procedure was not followed by nurses for medication administration. It happens when the nurses just copy down the name of patient in a piece of paper during pass over the report , without rechecking in the patient’s medication administration record. This unintentional act sometimes will lead to medication administration error when bed of the patient is exchange with another patient or the patient has been transferred to the other ward or may be discharged from the hospital .

There is also happen an error due to some of the nurses borrowing medication from another patient’s cart and administering an unlabelled medication or syringe. This improper practice will harm the patients and can cause medication administration errors. On the other cases, the nurses do not follow the correct time for medication administration. For instance, they just merely combine the medication that should be given at 4p.m with 6p.m. In that case, the effectiveness and toxicity of medication can be query. Thus, medication error can be some way again linked to an inconsistency applying the six rights of medication administration.

Definition of terms

Nurses A person educated and trained to care for the sick or disabled;

One that serves as a nurturing or fostering influence or means

(C.L.R James,2009 )

Working experience Work experience is the linking of a period of activity in a work

setting (whether paid or voluntary) to the programme of study,

irrespective of whether the work experience is an integral part

of the programme of study(Harveyet al,2002)

Incident Any other incident in which researcher is unsure about exposure

potential.

1.3 SIGNIFICANCE OF THE STUDY

Medication administration is a crucial part in nursing . Having a study concerning the incident of contributing factors that lead to medication error is important as this study creates awareness about the medication error and it consequences will affect patient’s safety. Such prevention methods could be taken to reduce the cases of medication error in hospital setting. Through this study, the management team of the hospital may take a serious action to solve the problem arised. Besides that, the nurses may realize the significance of medication administration process to overcome the factors that contribute to medication administration error.

Furthermore, nurses need to perform their duty in ethical manner and obey the correct standard procedures as guided by the ministry of health. The function beyond the limit of nursing practice acts or one’s ability is to endanger client’s life will put the nurses open to malpractice suits such medication administration error. Therefore, it is crucial part for nurses to always be aware of entire the medication administration process in order to maintain the safety of the patient.

1.4 RESEARCH OBJECTIVE

1.4.1 General Objective

The general objective for this study is to provide reasons about incidence of factors that contribute to medication error among the nurses. This study also helps to determine the barrier towards medication error which can used as guidelines for the nurses to be more caution on certain situation during administering medication in the hope of facilitating improvements to medication administration processes.

1.4.2 Specific Objective

The specific objectives of conducting this research are:

1) To identify the most factors which contribute to medication error

2) To indicate the relationship between working experience with all the contributing factors which potentially lead to medication error

1.5 RESEARCH QUESTIONS

What are the commonest factors that contributed to medication error perceived by nurses?

Is there any relationship between working experience with all the contributing factors which potentially lead to medication error?

1.6 ADVANTAGES OF RESEARCH

1. This study able to provide reasons about factors that contribute to medication error among the nurses.

2. This study helps to determine the barrier towards medication error which can used as guidelines for the nurses to be more caution on certain situation during serving medication

LITERATURE REVIEW

Introduction

Nurses are the group of health care providers who are closest to the patients. They have a major responsibility in administration of medication for patients, particularly in the wards. The issue of medication administration error (MAE) within the acute-care setting has long been the focus of research. Since nurses are intimately involved in the delivery of medications and the final person who occupy the link on medication administration, thus they are accountable for the responsibilities in medication error. It is important for nurses to understand the factors that contributed to medication administration errors in view of the fact that the burden of reporting medication error falls heavily on nurses.

Prevalence of medication error

Medical errors harm an estimated 1.5 million people and kill several thousand each year in the United States of America (Joint Comission International ,2007).In Malaysia the Malaysian government does emphasize on the medication safety whereby the government encourages researchers to conduct research on medication safety (Institute for Health Systems Research ,2008). In view of the fact that the prevalance of medication administration error is increasing globally, the serious action should be taken to minize it from occur.

Medication

The oxford Concise Medical Dictionary stated that, medication is “a substance that is administered by mouth, applied to the body, or introduced into the body for the purpose of treatment” (p.417).

Medication Administration

In administration of medication, the nurses must follow several principles that have been set up to prevent medication administration error. While administering medication, the nurses should implement the Six Rights to make sure the effectiveness of the drug effects and gain improvement in treating the disease. The six rights are involved before, during and after giving the medication. According to Bennet (2008), the six rights of medication administration includes the following; right medication, right dose, right client, right route, right time and right documentation. It is a must for the nurses to follow the standard protocol outlined for the implementation of medication administration.

Medication administration error

An article from joint comission international (2007) stated that “errors are common as medications are procured, prescribed, dispensed, administered, and monitored but, they occur most frequently during the prescribing and administering actions”. Since, the parts of administering process are bound to nurses’ job, so that they are responsible for their action and conduct. Mayo et al (2004) found that “some medication errors are not reported because nurses are afraid of the reaction they will receive from the Nurse Manager”. Hence, the real incident of medication error that occurred cannot be measurable since the nurses do not take responsibility to report the incident. Medication usage is a multidisciplinary process, which begins with the doctor’s prescription, is followed by the review and provision of medications by a pharmacist, and ends with the preparation and administration of the medication to the patient by a nurse. Inadvertent errors or accidents are encountered if there is a breakdown at any stage in this process, which leads to overwhelming consequences for the patient and for the career of the healthcare professional (Gladstone 1995). The impact of medication errors can be devastating to the confidence and self-esteem of the healthcare professional. Consequently, healthcare professionals are unwilling and indisposed to report any medication error unless there is an obvious harm to the patient.

Factors that contribute to medication error

Nurses need to prioritize significant responsibilities for safe patient care. In this hectic and stressful environment, serious medication errors are appearing significantly as a basis for successful malpractice cases against nurses (Lilley et. al, 2005). Proper medication process and system analysis approach are the essential link in the prevention of medication errors from occurring in health care setting. Asim and Nagy ( 2007) in their study showed that there were statistically significant differences in responses across the participant’s years of experience and the current clinical working area about the medication error to occurred. Research done by Fu et al.(2007) showed that medical wards and intensive critical units are the commonest areas for medication error.

Knowledge and practice

Henry (2005) revealed that, most of the types of medication administration errors occurring are due to omission of dose, wrong doses. The other study done by Fu et al. (2007) showed the wrong dose is at the highest to occur. Undeniable to say that, most of the errors can occur when the nursing duty during medication administration is not taken seriously. In addition, medication error can occur due to nurse attitude who do not check whether the right patient received the right medication. Medication administration error can occur when the nurse failed to check the patient’s arm band with the patient’s medication administration record or calling the patient by name to make sure the right patient receiving the medication. According to (Nancy et.al 2003 ; Ulanimo et al, 2007) through their observations that had been done, they found that nurses were failing to compare the patient’s wristband with the medication administration record before giving the medication to the respected patient.

What’s more, spelling errors and the similarities amongst the appearance different medication can cause confusing to the nurses. Unfamiliarity with drug medication such as new drug name with similar drug packing can cause medication administration error Fu et al (2007). The potential for medication errors will increase and leads to injury to the patient. Cases reported by FDA-Food and drug administration (2008); medication errors associated with Flomax and Volmax, Zantac and Zyrtec caused patient to suffer. For that reasons, unfamiliarity with the medication can cause the medication error to occur.

Besides drug administration, there are other factors that lead to medication errors taking place such as interruptions while administering the medication. In the research done by Pape et al.( 2005) ,it mentioned that conversations with other staff members and visitors or multi-tasking that occurs during medication preparation and administration can result in errors. Thus, the normal procedures for checking the six rights are easily neglected. So that, reducing unnecessary conversation and other distractions is an important aspect in administering medication safely to patients.

Personal issues

Abandon the six essential rights of administering the medication, are latent conditions evidenced to be a part of factors that contribute to medication error. Personal factors mentioned in connection with prescribing errors included physical and mental well being, skills, and knowledge. However, there are few associated factors that contributed to medication error to happen among nurses. The factors are time pressures, fatigue or exhaustion a part of nurses (Mayo et al; Ulanimo et al, 2007). Study by Nick Barber et al (2002), 18 interviewees reported that they had felt tired, hungry, or unwell, and that these factors might have contributed to the error. A considerable percentage of reported that they omitted to give medication or gave at the wrong time, and also indicated that other nurses gave incorrect medication or incorrectly administered treatments; practice issues which were related to the nursing shortage and causing moral distress (Marj.T Mrayyam,2011).

Healy and McKay (2000) also found workload to be most significantly correlated with mood disturbance. However, Payne (2001) did not find a significant relationship between workload and burnout, although levels of burnout in her study were lower than in related studies. The reasons for this variation are unclear, but seem likely to include differences of stress ‘hardiness’ (Simoni & Paterson 1997), of coping mechanisms (Payne 2001), of age and experience (McNeese-Smith 2000) or of the level of social support in the workplace (Ceslowitz 1989, Morano 1993, Healy & McKay 2000).

Hospital setting and workload

The terms “hectic”, “hassly”, and “busier than average” were used to describe workload. Sometimes, workloads made nurses change their usual practice to try and save time From the study, it was shown that, it is not only the practice itself that contribute to medication administration error but other external factors can also contributed to medication errors such understaffing, inexperience nurses, design deficiencies, and inadequate equipment while administering the medication( Carlton & Bleggen, 2006). Nurses and workload is one of the major factors that should be considered .Most of the hospitals are lacking of nurses and this small issues will lead to big impact of nurses practice. Stordeur et al. (2001) attempted to rank stressors in order of severity of impact, the main ones being ranked as:

• High workload,

• Conflict with other nurses/physicians,

• experiencing a lack of clarity about tasks/goals,

• a head nurse who closely monitors the performance of staff in order to detect mistakes and to take corrective action.

Lack of staff

Staffing issues were also mentioned and included inadequate staffing, the effects of new or locum staff, and attending to another doctor’s patient. Providing cover for absent colleagues not only increased workload but also meant that care was being given for patients the doctor did not know. Several doctors drew the distinction between those patients whom they had admitted and knew throughout their stay, and those whom they had to take over for only part of their treatment.

The most commonly used unit-level workload measure is the nurse-patient ratio( Pronovost PJ et al (2000). The nurse-patient ratio can be used to compare units and their patient outcomes in relation to nursing staffing. Previous research provides strong evidence that high nursing workloads at the unit level have a negative impact on patient outcomes (Olson V et al, 2004). Hospital nurse staffing is a matter of major concern because of the effects it can have on patient safety and quality of care. Nursing-sensitive outcomes are one indicator of quality of care and may be defined as “variable patient or family caregiver state, condition, or perception responsive to nursing intervention (Needleman et al, 2003)

Briefly, medication administration error should be avoided because direct results of the error can cause harm to the patient as well as increased health care costs. Moreover, indirect results include harm to nurses in terms of professional and personal status, confidence, and practice. Thus, to maintain the professionalism in delivering of care to the patient, medication administration process should take seriously among the nurses. In a 1999 study conducted by the Institute of Medicine, entitled “To Err Is Human: Building a Safer Health System”, It is estimated that medication errors cause over 7,000 deaths annually.

This chapter will explain on the research methodology of the study consist of research design, population, sample, setting and data-collection instrument.

2.1 Research design

Research design is an overall plan for conducting study on order to answer the research questions (Polit et al; 2001: 67). The research designs signify the steps which will be used in conducting the research. According to Burns and Grove (2001:223) , research design is a guideline for the research process in order to achieve the intended result which will be the reflection of reality. Polit (1999:155) state that the research design will includes the most important decisions in research methodology that researcher makes in conducting the study.

This study used cross-sectional; quantitative non-experimental correlation study using assisted-administered questionnaire to reveal the question incident of contributing factors that lead to medication error.

2.2 Population and sampling

Population is an entire group of people that is interested to the researcher as define by Brink (1996:132-133).Burns and Grove (2001:366,810) define population as the whole set of individuals who meet the sampling criteria. A sample taken from population and it will include in the study which representing research population, if random sampling procedures has been adhere to. Random sampling would give every individual in the whole population the same and unbiased chance of participating in the study.

Simple random sampling will be used in this study. The respondents are consisting of Registered Nurses in Hospital Tengku Ampuan Rahimah, Klang (HTAR) .The sample will be taken randomly from several discipline in HTAR.

In order to get significant result, a sample size calculation formula has been used to determine the size of the sample for this study.

Inclusion criteria for respondents are:

Registered Nurse with Malaysia Nursing Board

Understand Malay and English language and generally healthy.

Have working experience at least 1 year.

The participants are involves in direct patient care.

Have an experience in administering the medication

Exclusion criteria area:

Unregistered nurses with Malaysia Nursing Board

Have working experience less than 1 year

Do not have an experience in administering medication

2.3 Research setting

The study setting will be conducted in HTAR. The unit chosen is medical ward, surgical ward, Intensive Care Unit, Obstetrics and gynecology ward, Pediatrics ward, Emergency Department and orthopedic ward. HTAR is chosen because affordable cost and time constrain for me.

2.4 Study period

Data collection

February to April 2011

Data Processing/ analysing and writing up

April to May 2011

Grantt Chart (refer to appendix )

First phase

Screening for initial data from hospital record (secondary Data) in Hospital Tengku Ampuan Rahimah

Identify the discipline units to be study

Second phase

Pilot study done to confirm feasibility of the study

Collection and analyzed the questionnaire

Third phase

Obtain consent from subject

The data are collected by using questionnaire in order to obtain the information regarding the study

Fourth phase

Analyze the data collection and writing up

2.5 Data collection

Dempsey and Dempsey (2000:195) define questionnaires is a paper and pencil data collection instrument filled in by the respondents for the purpose of the research study. Characteristics of questionnaires had been listed out by Gillham (2000: 5-8) as below:

A questionnaire is less expensive than interview. A lot of sample can be taken within short period of time. Questionnaires can reduce cost of using telephone and travels thus it is also feasible to be used by researchers who have full time jobs.

Questionnaires are an easy way to get more information within a limited period of time.

Respondents able to complete the questionnaires at their own time without pressure.

Anonymity can be guaranteed. Reassuring the respondents that no one will know any feedback from them. This aspect was deemed to be very important in this study as the respondents could be reassured that they could state their honest opinions about factors might contribute to medication error without fear that employer would take action to them if their knowledge level is low. The research contents will display out numbers, facts and figures .No names should be mentioned not even the researcher nor did the supervisor know who provided which answers for specific questions.

No different questionnaires are distributed; all questionnaires are standardized

to limit the bias.

2.5.1 Development of questionnaires

The development of questionnaires was based on the literature review (Chapter 2) and other research instrument used in similar studies. The questionnaire is compiled and discussed by researcher and supervisor. Changes suggested were implemented. Most of the changing pertaining to rephrasing specific items so that each items had only issues to address rather than multiple issues. There is part of questionnaires that had been corrected and combined from previous study to ensure the objective of study answer.

2.5.2 Pilot Study

Pilot study was done to determine feasibility of the instrument .This shows a trial administration of newly developed questionnaires in order to identify the potential -problem encountered by participant. Brink and Wood (1998:259; 373) explained that pre-testing enabled the researcher to interact with the participant similar but they were exclude from the real respondents participating in actual study. These ensure the researcher to predict what would happen to the main study regards to participation.

Pilot study was conducted with five staff nurses with year of experience more than 1 at the same hospital but different target unit which they will not selected to participate in the actual study. No apparent problems were encountered during the completion of the questionnaires.

2.5.3 Structure of the questionnaires

The questionnaire is conducted in Malay/English language and is assisted-administered questionnaire. The questionnaires will be distributed to the nurses in the unit by the researcher. The researcher needs to explain about the objectives, target population and significance of the study. Some of the respondents will answer the questions by themselves and some of them need assistance while answering the questionnaires. The data obtained will be statistically analyzed using SPSS software. An effective strategy for nurses will be formulated based on the findings. The questionnaire is distributed to the whole chosen unit consist of 30 registered nurses in HTAR.

The questions based on a structured questionnaire that composed of three parts.(refer to the appendix)

Part 1 that consists of demographic data : year of working experience

Part 2 – Question consists of six incident of contributing factors which potentially lead to medication error.

Factor 1: This section using closed -ended question (dichotomous question) directed towards the knowledge regarding the process for medication administration. This questionnaire edited from study that had done by Raja Lexshimi R.G et al (2009).

Factor 2-6: This section is questions regarding factors contribution to medication error edited from the result of study done by Fu et. al (2007) which categorized into five categories which using Likert scale. The respondents are asked to indicate how much the declarative statements given from each category will influence to contribute to medication error.

Personal neglect

Heavy workload

Unfamiliarity with medication

New staff

Complicated order

2.6 Data Analysis

To identify the level of knowledge among nurses towards serving medication .It is also to identify the most incident of contributing factors which lead to medication error. A significant value of 0.05 was used to test for significance for all statistical tests. The chi square analysis was performed to determine the association between incident of contributing factors and the years of experience. The data collected will be analyzed using Statistical Package for Social Science (SPSS) version 18. 0.

2.7 Research Variable

Dependent Variable

In this study, the dependent variable is years of experience

Independent Variable

In this study, the independent variables are the 6 incident of contributing factors

; Knowledge, Personal Neglect, Heavy Workload, Unfamiliar Medication,

Newly staff and Complicated order.

2.8 Validity and Variable

According to Polit and Hungler (1999:418), validity is the degree to which an instrument measures what it is designed to measure. The content of the questionnaire is adapted from the previous survey and study that had been done. Moreover the questionnaire used will be reviewed by a philosophy doctors (PhD).

2.9 Ethical consideration

Permission from HTAR will be obtained from hospital authority to conduct this research. Each participants who involve in this study will be given inform consent. Furthermore, before distributing the questionnaire, each participant will be explained about the purpose of the study and consent form was given to the participants. They are free to agree or decline their participation in the study at any time. All information obtained from the participants will be kept confidential. The participants took 15 to 30 minutes to answer the questionnaire and the researcher collected it back after finished answering. Polit and Hungler (1999: 131-134) revealed that researcher therefore need to exercise care that the rights of individuals and institution are safeguarded.

Administer medication is an everyday activity in nursing practice and nurses should have enough knowledge in order to perform this important job. The finding of these study shows that nurses knowledge in serving medication is sufficient. Most of the f=29 (96.7%) registered nurses able to answer the questionnaire correctly automatically make knowledge as low incident that will contribute to medication error. Reflected from the result, King (2004) and Coombs et al have similar result which reported the same. Nurses have the knowledge but the knowledge is limited especially on drugs administration. 43.3% did not know the frequent recommended site for heparin injections is at the abdomen (Caffrey, 2003).Nurses should improved their knowledge and highlight on different route of administer medication. Gerry & Helen (2003) reported that time-span of experience and level of professional education was linked with level of knowledge in the administration of medications. Having extra educational qualifications among nurses were found to have contributed to a improved knowledge of medications.

However in this study, 26.7% nurses practice wrongly which they did not check the patients ID band prior administering medication. It is also surprise 23.3% nurses violate the practice by administering medication prepared by other nurses. Benners and others (2002) agree source of errors include delivering too much medication, missed doses; wrong route; and wrong medication deliver due to misidentification of client.

Mattan (1998) revealed that administering medicine effectively was a aspect of practice but it lacked quality, which is due to poor knowledge in pharmacology and practice. Manias et al. (2004) indicated that nurses infatuated the necessary knowledge and skills in medication administration such as monitoring effects of medication, assessing and evaluating patient’s condition prior to medication administration. In many cases drug errors arise as a result of nurses failure to follow policy (Keill and Johnson, 1993).

2) Personal Neglect

From the data analyse, 18 (60%) nurses show personal neglect is in the low incident contribute to medication error. Nevertheless 4(13.3%) nurses indicate in the middle of administering drug, there was interruptions by others. A new study shows that interrupting nurses while they’re nursing to patients medication needs increases the likelihood of error. As the number of distractions increases, so do the number of errors and the risk to patient safety.   According to the study reported in the April 26, 2010 issues of the Archives of Internal Medicine, four interruptions in the route of a single drug administration doubled the likelihood that the patient would experience a major mishap. 26.7% nurses indicate that personal neglect as a medium indicator of medication error.

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